General characteristics of hospital stays related to pressure ulcers

Table 1 compares the utilization and patient characteristics of both principal and secondary pressure ulcer hospitalizations to hospital stays for all other conditions among adults 18 years and older. In 2006, more than 90 percent of pressure ulcer-related adult hospitalizations noted pressure ulcers as the secondary diagnosis, rather than the principal reason for admission. Stays principally for pressure ulcers were slightly longer than those with a secondary pressure ulcer diagnosis (14.1 days versus 12.7 days). Furthermore, the length of stay for hospitalizations principally for pressure ulcers was nearly three times longer than hospitalizations with no diagnosis of pressure ulcers (14.1 days versus 5.0 days). Though stays principally for pressure ulcers were longer than stays with a secondary diagnosis of pressure ulcers and those with no pressure ulcer diagnosis, the average cost per day ($1,200) was lower—nearly $400 less than secondary pressure ulcer stays ($1,600 per day) and $800 less than stays for all other conditions ($2,000 per day).

Table 1

Characteristics of hospitalizations related to pressure ulcers compared to hospital stays for all other conditions among adults 18 years and older, 2006.

Stays related to pressure ulcers were more likely to be discharged to a long-term care facility (e.g. a skilled nursing facility, an intermediate care facility, or a nursing home), as compared to hospitalizations for all other conditions. In fact, over half of principal pressure ulcer stays (53.4 percent) and secondary pressure ulcer stays (54.5 percent) were discharged to long-term care—more than three times the rate of hospitalizations for all other conditions (16.2 percent).

As a principal diagnosis, just over half (50.3 percent) of adult patients hospitalized for pressure ulcers were male. Conversely, adult patients with a secondary diagnosis of pressure ulcers were less often male (46.9 percent), which was similar to the percentage of male stays for all other conditions (45.9 percent).

In-hospital mortality was also higher for pressure ulcer-related hospitalizations, especially among those hospitalizations with a secondary diagnosis of pressure ulcers. In-hospital death occurred in 11.6 percent of stays with pressures ulcers noted as a secondary diagnosis, as compared to 4.2 percent of stays principally for pressure ulcers and 2.6 percent of stays for all other conditions.

Differences in hospital stays related to pressure ulcers, by age

Compared to stays for all other conditions, adult patients hospitalized with pressure ulcers were older. As shown in figure 2, nearly three out of four adult stays with a secondary diagnosis of pressure ulcers occurred among patients older than 65 years old, resulting in a mean age (71.9 years) that was more than ten years older than patients hospitalized with no diagnosis of pressure ulcers. Nearly half (49.0 percent) of stays with a secondary pressure ulcer diagnosis occurred among patients aged 65 to 84 years, while this age group accounted for 37.1 percent of all non-pressure ulcer stays. Moreover, secondary pressure ulcer stays had the highest concentration of patients aged 85 years and older (23.0 percent).

Figure 2

Nearly three out of four adult patients hospitalized with a secondary pressure ulcer diagnosis were 65 years and older, 2006^*. ^* Hospital stays occurring among persons less than 18 years old have been excluded. Source: AHRQ, Center for Delivery, Organization, (more...)

Patients 65 and older accounted for 56.5 percent of adult patients with a principal diagnosis of pressures ulcers. Hospital stays principally for pressure ulcers had a mean age (65.3 years) that was nearly four years older than the mean age for patients hospitalized for all other conditions (61.5 years).

Differences in hospital stays related to pressure ulcers, by primary payer

Given the prevalence of older patients hospitalized with pressure ulcers, it is not surprising that the most common primary payer for hospitalizations related to pressure ulcers was Medicare (figure 3). In 2006, nearly three out of four hospitalizations with a pressure ulcer diagnosis were billed to Medicare, as compared to just over half of hospitalizations for all other conditions. Although patients 65 years and older accounted for about 57 percent of adult stays principally for pressure ulcers, Medicare covered 73.8 percent of these stays, suggesting that disabled individuals may account for a large share of hospitalizations with a principal diagnosis of pressure ulcers. In fact, government payers—Medicare and Medicaid—bore the greatest burden of hospitalizations principally for pressure ulcers; Medicaid patients accounted for an additional 12.5 percent of hospitalizations with a principal diagnosis of pressure ulcers.

Figure 3

Medicare was the most common payer of adult hospitalizations related to pressure ulcers, 2006^*. ^* Hospital stays occurring among persons less than 18 years old have been excluded. Source: AHRQ, Center for Delivery, Organization, and Markets, Healthcare (more...)

Patients with private insurance accounted for about ten percent of all pressure ulcer-related hospital stays, while comprising nearly 30 percent of all non-pressure ulcer stays. Only 1.4 percent of all pressure ulcer-related stays were uninsured compared with approximately six percent of adult stays for all other conditions.

Most common reasons for hospitalizations related to pressure ulcers

Table 2 shows the most common principal reasons for hospitalizations during which pressure ulcers were also present. The most common principal reasons for hospitalization among stays with secondary pressure ulcer diagnoses included septicemia (16.1 percent of all pressure ulcer-related hospitalizations had this principal diagnosis), pneumonia (6.3 percent), urinary tract infection (5.6 percent), respiratory failure (4.3 percent), and aspiration pneumonitis (3.7 percent). Of particular note is that 13.5 percent of all stays principally for septicemia had pressure ulcers noted as a co-existing condition, and 10.7 percent of all stays principally for aspiration pneumonitis had pressure ulcers noted as a secondary condition.

Table 2

Top 10 most common principal reasons for hospitalizations during which pressure ulcers were also present among adults 18 years and older, 2006.

Among hospital stays that were principally for pressure ulcers, other concomitant conditions included anemia (31.2 percent), urinary tract infections (30.5 percent), paralysis (29.2 percent), fluid and electrolyte disorders (26.1 percent), nutritional deficiencies (23.4 percent), diabetes without complications (20.6 percent), and dementia (20.4 percent).² However, common concomitant diagnoses and their distribution varied by age (figure 4). Paralysis and spinal cord injury were prominent among younger patients, while fluid and electrolyte disorders, nutritional disorders, diabetes without complications, and dementia were more often seen among patients 65 and older.

Figure 4

Among hospitalizations principally for pressure ulcers, common co-existing diagnoses varied by age, 2006. Source: AHRQ, Center for Delivery, Organization, and Markets, Healthcare Cost and Utilization Project, HCUPnet, Nationwide Inpatient Sample, 2006 (more...)

Diagnoses, ICD-9-CM, and Clinical Classifications Software (CCS)

The principal diagnosis is that condition established after study to be chiefly responsible for the patient’s admission to the hospital. Secondary diagnoses are concomitant conditions that coexist at the time of admission or that develop during the stay.

ICD-9-CM is the International Classification of Diseases, Ninth Revision, Clinical Modification, which assigns numeric codes to diagnoses. There are about 13,600 ICD-9-CM diagnosis codes.

CCS categorizes ICD-9-CM diagnoses into a manageable number of clinically meaningful categories.³ This “clinical grouper” makes it easier to quickly understand patterns of diagnoses and procedures.

Case Definition

The ICD-9-CM codes defining pressure ulcers include diagnosis codes in the following range: 707.00–707.09.

Types of hospitals included in HCUP

HCUP is based on data from community hospitals, defined as short-term, non-Federal, general and other hospitals, excluding hospital units of other institutions (e.g., prisons). HCUP data include OB-GYN, ENT, orthopedic, cancer, pediatric, public, and academic medical hospitals. They exclude long-term care, rehabilitation, psychiatric, and alcoholism and chemical dependency hospitals, but these types of discharges are included if they are from community hospitals.

Unit of analysis

The unit of analysis is the hospital discharge (i.e., the hospital stay), not a person or patient. This means that a person who is admitted to the hospital multiple times in one year will be counted each time as a separate “discharge” from the hospital.

Costs and charges

Total hospital charges were converted to costs using HCUP Cost-to-Charge Ratios based on hospital accounting reports from the Centers for Medicare and Medicaid Services (CMS).⁴ Costs will tend to reflect the actual costs of production, while charges represent what the hospital billed for the case. For each hospital, a hospital-wide cost-to-charge ratio is used because detailed charges are not available across all HCUP States. Hospital charges reflect the amount the hospital charged for the entire hospital stay and does not include professional (physician) fees. For the purposes of this Statistical Brief, costs are reported to the nearest hundreds.

Primary payer

Payer is the expected primary payer for the hospital stay. To make coding uniform across all HCUP data sources, payer combines detailed categories into more general groups:

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Medicare includes fee-for-service and managed care Medicare patients.

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Medicaid includes fee-for-service and managed care Medicaid patients. Patients covered by the State Children’s Health Insurance Program (SCHIP) may be included here. Because most state data do not identify SCHIP patients specifically, it is not possible to present this information separately.

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Private insurance includes Blue Cross, commercial carriers, and private HMOs and PPOs.

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Other includes Worker’s Compensation, TRICARE/CHAMPUS, CHAMPVA, Title V, and other government programs.

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Uninsured includes an insurance status of “self-pay” and “no charge”.

When more than one payer is listed for a hospital discharge, the first-listed payer is used.

Discharge status

Discharge status indicates the disposition of the patient at discharge from the hospital, and includes the following six categories: routine (to home), transfer to another short-term hospital, other transfers (including skilled nursing facility, intermediate care, and another type of facility such as a nursing home), home health care, against medical advice (AMA), or died in the hospital.